West Chester University Department of Campus Recreation
Sport Club Informed Consent Statement
1. I am aware of my physical condition.
2. I am voluntarily participating in the aforementioned club.
3. I am aware that such participation may result in possible injury as a result of the nature of the sport and that I
am assuming any risk that may be involved in the sport.
I understand that part of the risk involved in undertaking any recreational activity is relative to my own state of
fitness or health (physical, mental, or emotional) and to the awareness, care, and skill with which I conduct myself in
that sport. I acknowledge that my choice to participate in the WCU Sport Club Program brings with it my assumption of
those risks or results stemming from this choice and the fitness, health, awareness, care and skill that I possess and use.
I understand that the personnel coaching and conducting the practice sessions and contests of the Sport Club
program may not be licensed, certified, or registered professionals. I accept the fact that the skills and competencies of
the volunteers will vary according to their training and experience and that no claim is made to offer assessment or
treatment of any mental or physical disease or condition by those who are not duly licensed, certified, or registered and
herein employed to provide such professional services.
I understand that the dangers and risks from my participation in the Intramural Sports Program may include
injury to virtually all internal organs and other aspects of the muscular/skeletal system, to other aspects of my body, and
general health and well being, including serious injury which may result in loss of life. I acknowledge that I am
responsible for my injuries I may sustain, that I may cause to others, and damage I may cause to the facilities.
I agree to indemnify and hold harmless the University, Student Services, Inc., PASSHE, the State System of Higher
Education, its Trustees, officers, agents and employees of the intramural sports program, from and against any and all
claims, liability, losses, third party claims, damages, costs, or expenses (including attorneys’ fees), from any responsibility
or liability in case of personal injury sustained by me or damage to property of others caused by me during or because of
participation in the activities of the Sport Club program.
Insurance Statement Agreement
West Chester University, the Department of Campus Recreation and Student Services, Inc., DOES NOT provide
any medical insurance coverage, and will not be responsible for any injuries sustained or caused as the result of your
choice to participate in the Sport Club program. It is our recommendation that you check with your parent’s medical
insurance provider prior to your participation in the program to ensure coverage if any injury occurs while participating
in the sport club programs at West Chester University. If you do not have medical insurance coverage, we recommend
that you purchase a plan for yourself to cover the medical expenses if you are injured. Any participant who
misrepresents or falsifies information concerning the acquisition of an insurance policy will be processed through the
University Judicial system (see Student Code of Conduct Handbook under “violations of the Student Code of Conduct).
Grade Release Agreement
I hereby authorize my grades to be released to my Advisor, Coach, and University Administrators in the
Department of Recreation and Leisure Programs.
Photo Release
I grant permission to West Chester University and its agents or employees, to use photographs taken of me for
use in University advertising and publications, both printed and electronic. I hereby waive any right to inspect or
approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in
the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation
arising from or related to the use of the photograph. I hereby agree to release, defend and hold harmless West Chester
University and its agents or employees, including any firm publishing and/or distributing the finished product in whole or
in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or
related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical
illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing,
reduction or production of the finished product, its publication or distribution.
I am 18 years of age or older and I am competent to contract in my own name. I have read this release before
signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to
address any specific questions regarding this release by submitting those questions in writing prior to signing, and I
agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
I understand that I may ask any questions or request further explanation or information about the Sports Club
program at any time before, during, or after my participation. I understand that the questions will be answered to my
satisfaction.
My signature below verifies that I have read, understood, and agree to the contests of these Statements in their
entirety.
___________________________
Name (Print)
___________________________
Signature
______________________
WCU ID#
___________________________
Sport
___________________
Date